Prevalence of Hyperemesis Gravidarum and Associated Factors in Arba Minch General Hospital, Gamo Gofa Zone, Southern Ethiopia

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C Clinics in Mother and Child Health DOI: 10.4172/2090-7214.1000285 ISSN: 2090-7214

Research Article Open Access

Prevalence of Hyperemesis Gravidarum and Associated Factors in Arba Minch General Hospital, Gamo Gofa Zone, Southern Ethiopia Gemechu Kejela1*, Shimelis Getu2, Tadla Gebretsdik2 and Tesfaye Wendimagegn2 1Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia 2School of Medicine, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia *Corresponding author: Kejela G, Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia, E-mail: [email protected] Received date: January 02, 2018; Accepted date: January 30, 2018; Published date: February 05, 2018 Copyright: ©2018 Kejela G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background: Nausea and vomiting of pregnancy (NVP) are common symptoms experienced during pregnancy. Both mild and severe symptoms can have significant morbidities and socioeconomic impact. Despite its frequency and associated distress, its exact cause is unknown. No significant study was done addressing this particular important issue in our country and our globe as well and this study will serve as a bench mark for future work on the topic.

Objective: To assess prevalence of hyperemesis gravidarum and associated factors in women attending antenatal care in Arba Minch general hospital.

Methods and materials: A descriptive facility based cross-sectional study was done in Arbaminch general hospital. Semi-structured questionnaires were administered to a sample of 183 admitted pregnant women. Descriptive statistic was used to summarize data. SPSS 20 is used to analyse the data.

Results: The prevalence of hyperemesis gravidarum was 8.2%. It was found out that 80% had symptoms in the 1st trimester, 2.1% continue to have it after 1st trimester, and 85% were triggered by smell and taste.

Conclusions and recommendations: Prevalence and associated factors of hyperemesis gravidarum in this study are similar to other studies. Sensory stimuli were major trigger of symptoms.

Keywords: Hyperemesis gravidarum; Arba Minch; General hospital have deleterious effects on the health of the foetus, the baby, and the mother [7]. Introduction According to the Hyperemesis Education and Research Foundation, Nausea and vomiting is a common experience for women in conservative estimates indicate that, HEG can cost a minimum of $200 pregnancy (NVP). Symptoms are usually limited to the first trimester, million annually in in-house hospitalizations in the United States [8]. but can continue throughout pregnancy and even persist until birth In a related economic analysis, Piwko et al. projected that the United [1]. The severity of nausea and vomiting may affect the physical and States spends nearly $2 billion in costs attributed to pregnancy-related emotional health of the pregnant women, family, social and nausea and vomiting; 60% of this expenditure is result of direct costs occupational functioning [2], the stages of maternal role attainment, (e.g., drugs, hospital admission), and 40% is a result of indirect costs and even outcomes for the unborn child like low birth weight [3]. (e.g., time lost from work) [9]. The exact etiologic factor for nausea and vomiting is unknown, but In Germany, in 2005, the yearly cost of hospital admittances alone it is widely agreed that it is a multifactorial condition with genetic, for hyperemesis gravidarum was about 28 million Euros, and the cost physiological, behavioural, dietary, social, and psychological of lost working hours and outpatient treatment is not even included in contributing determinants [4]. However, the reports regarding these this amount [10]. determinants continue to be contradictory and are often restricted to There is increasing evidence that NVP has emerged as a common either the first trimester of pregnancy or hyperemesis gravid arum phenomenon among urbanized human population with increased (HEG), the most severe form of NVP [5]. The overall clinical genetic heterogeneity as its occurrence is rare among foraging symptoms are believed to be highly variable and tend to be affected by population such as the Bushmen of South Western Africa and the the age, marital status, place of residence, race/ethnicity, cultural, Amazonian Amerindian tribes with well documented genetic social, and educational status of the individual [6]. homogeneity [11]. The literatures has shown that worry, stress, anxiety, depression and Apart from the ethnic difference in the occurrence of NVP, some unintended pregnancy as well as cigarette, alcohol and drug use can all anthropometric and demographic factors have also been associated with NVP as studies have reported association between maternal age,

Clinics Mother Child Health, an open access journal Volume 15 • Issue 1 • 1000285 ISSN:2090-7214 Citation: Kejela G, Getu S, Gebretsdik T, Wendimagegn T (2018) Prevalence of Hyperemesis Gravidarum and Associated Factors in Arba Minch General Hospital, Gamo Gofa Zone, Southern Ethiopia. Clinics Mother Child Health 15: 285. doi:10.4172/2090-7214.1000285

Page 2 of 5 body weight, parity, sex of foetus, family history and experience in The dependent variable for this study was hyperemesis Gravid previous pregnancy as factors which bears increased risk of developing arum, which is defined as severe (un able to tolerate per mouth severe NVP [12-15]. feeding) form of nausea and vomiting in pregnant mothers characterized by significant weight loss (5% weight loss from pre HEG can be associated with serious maternal and foetal morbidity pregnancy) and ketonuria [10,16]. For data collection, 5 midwifery such as Wernicke’s encephalopathy, foetal growth restriction, and even nurses were recruited as data collectors and 3 MPH professionals were maternal and foetal death [16-19]. In some instances long-lasting, very recruited as supervisors. Data was collected by interviewing admitted intensive vomiting, might in rare cases lead to esophageal mucosal pregnant women using the structured questionnaire after letter of injury/tear (a Mallory-Weiss syndrome), rupture of oesophagus or permission was taken from Arba Minch University ethical review spleen, choroid bleedings, transient hypothyroxinemia, pneumothorax board. as well as neurological complications such as myelinolysis of the cerebellum or Wernicke encephalopathy caused by lack of vitamin B1 To control the quality of data, before data collection, training was [16]. given for data collectors and supervisors. Pre-test was conducted on 5% of the sample and then possible adjustments or modifications were Prim gravidity, null parity, excessive salivation and food aversion made based on the result of pre-test. In addition close supervision was were significantly associated with nausea and vomiting during conducted by supervisors. pregnancy [20-24]. Significant associations were also observed between admission for severity and being unmarried, loss to work, To know the association between variables univariate and bivariate affected relationship, more frequent vomiting, and early onset of analysis was done using binary logistic regression. Finally variables symptoms. Severe frequency of vomiting was a major factor associated with P-value of <0.05 will be considered as statistically significant with admission for severity and loss to work [25]. association with the outcome variable. In our country, the study conducted in Addis Ababa showed that, the prevalence of nausea and vomiting during pregnancy was 74.5%, Results with 4.4% being admitted for severe symptoms. It also found out that 91% had symptoms in the 1st trimester, 2.1% after mid pregnancy, and Socio-demographic characteristics 85% were triggered by smell and taste. The age distribution of the study subjects ranged from18–45 years, Despite the presence of a problem and its severity in Ethiopia, there 95 (51.9%) were between the ages of 25–34 years with a mean age of is scarcity of studies that show the magnitude and factors that 28.04 ± 6.14 years. Most were Gamo 105 (57.4%) in ethnicity, living associated with the problem. So, the main aim of this study was to together 169 (92.3%), completed secondary education 121 (66.1%); assess the prevalence of hyperemesis gravidarum and associated employed 89 (48.6%) (Table 1). factors in women attending Arba Minch general hospital. The study helps all women affected by the problem, health professionals, Socio-demographic variable Frequency Percentage researchers, government bodies and NGOs to solve the problem. In Age in year addition, it provides base line information for further studies to be carried out and also will add a bit to the literature pool of the library ≤ 18 9 4.9 [26-28]. 19-24 50 27.3

Methods 25-34 95 51.9 Institution based cross sectional study was conducted in Arba ≥ 35 29 15.8 Minch general hospital from January 21-January 30, 2016. The hospital Place of residence is found in Arba Minch town, the capital city of Gamo Gofa zone. Arbaminch is located at 505 km from Addis Ababa, the capital city of Rural 62 33.9 the country. The town has 1 zonal hospital and 2 governmental health centres and 69 private health institutions. According to the figure from Urban 121 66.1 Central Statistical Agency 2007, the town has a total population of Occupation 90,000, of which reproductive age women accounted for 42,792. Farmer 50 27.3 All pregnant women admitted to gynaecology/obstetric ward during the study period were the source population and all women admitted G/ment employee 45 24.6 to gynaecology/obstetric ward during the study period, which fulfil the inclusion criteria were the study population. Self-employee 44 24 The sample size was calculated using the single population Student 18 9.8 proportion formula by using the following assumption; prevalence of Others 26 14.2 hyperemesis gravid arum of 4.4% from the study conducted in Addis Ababa teaching hospitals, the margin of error of 3% and 95% Educational status confidence interval. The final calculated sample size was 183. Illiterate 40 21.9 Systematic sampling method was used to interview admitted pregnant mothers to the hospital. Primary 22 12

Secondary 44 24

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Above secondary 77 42.1 Pregnancy condition of respondents

Ethnicity Pregnancy condition of respondents shows that, 81.4% of the pregnancy was planned and supported and only 1.6% was planned and Gamo 105 57.4 unsupported (Figure 1).

Wolayta 14 7.7

Konso 45 24.6

Other 19 10.4

Religion

Muslim 6 3.3

Orthodox 80 43.7

Protestant 80 43.7

Others 17 9.3

Marital condition

Live together 169 92.3

Not live together 14 7.7 Figure 1: Pregnancy condition of pregnant women who were Table 1: Socio-demographic characteristics of women who are admitted to gyn/ob ward during the study period, AMGH, 2016. admitted to gyn/ob ward in study period, AMGH, 2016.

Reproductive health characteristics of respondents Prevalence of hyperemesis gravidarum

S. No Reproductive variable Frequency Percentage Among the respondents, 15 (8.2%) had severe NVP that required admission to a hospital. The most common triggering factors were; 7 Parity (46.7%) triggered by smell, 4/15 (26.7%) by taste and 4/15 (26.6%) by Primipara 38 20.8 both smell and test (Figure 2). 1 Nullipara 34 18.6

Multipara 111 60.7

Gestational age

First trimester 29 15.8 2 Second trimester 2 1.1

Third trimester 152 83.1

Pregnancy order

3 Single 176 96.2

Twin 7 3.8

Time of onset of sever NVP Figure 2: Triggering factors of HEG in pregnant women admitted to gyn/ob ward during the study period, AMGH, 2016. First trimester 130 80 4 Second trimester and 33 20 above Discussion Table 2: Reproductive health related characteristics of pregnant women In this study, the prevalence of severe NVP is 8.2% which is lower who were admitted to gyn/ob ward in study period, AMGH, 2016. than the Canadian and the Swedish reports of 19% and 17% respectively [21,22] and higher than the study done in Addis Ababa. Most of the respondents were in the third trimester 152 (83.1%) and The difference may be because of the difference in methodology and only 2 (1.1%) were in the second trimester. Primipara, nullipara and definition of severity used. In our study, severe NVP was defined as a multipara account for 38 (20.8%), 34 (18.6%) and 111 (60.7%) symptom that required hospital admission while in other studies a respectively (Table 2).

Page 4 of 5 NVP index scale measure was used for grading severity of nausea and References vomiting [29]. 1. OʼBrien B, Evans M, White-McDonald E (2002) Isolation from “being In this study, the onset of symptoms in the 1st trimester was 80% alive”: coping with severe nausea and vomiting of pregnancy. Nurs Res 51: and only 20% occurred after 1st trimester. This finding is similar with 302-308. different studies reported, 90% onset of symptoms in first trimester 2. Chou FH, Chen CH, Kuo SH, Tzeng YL (2006) Experience of Taiwanese and only 5% after 22 weeks of pregnancy [23,24]. women living with nausea and vomiting during pregnancy. J Midwifery Women’s Health 51: 370-375. The onset of HEG is decrease with increasing gestational age. This is 3. Zhou Q, OʼBrien B, Relyea J (1999) Severity of nausea and vomiting reasonable since the natural history of NVP is gradual improvement of during pregnancy: What Does It Predict? Birth 26: 108-114. symptoms as pregnancy progresses corresponding with the onset, peak 4. Lee NM, Saha S (2001) Nausea and vomiting of pregnancy. Gastroenterol and decline of maternal HCG levels. This association is well Clin North Am 40: 309-334. demonstrated in the present study as well. 5. Brown SS, Eisenberg L (Eds) (1995) The best intentions: unintended pregnancy and the well-being of children and families. Washington DC: As most reports, of the socio-demographic variables studied, the National Academy Press. problem is high among those who were not being partnered and not 6. Buckwalter J, Simpson S (2002) Psychological factors in the etiology and being employed. This finding is different from other studies and these treatment of severe nausea and vomiting in pregnancy. Am J Obstet differences may have resulted from the difference in methodology and Gynecol 186: S210-214. study population. 7. Chin RKH, Lao TT (1988) Low birth weight and hyperemesis In similarity with other studies, HEG is higher in nullipara women, gravidarum. Eur J Obstet Gynecol 28: 179-183. compared to multipara women. This may be due to stress and exposure 8. Goodwin TM (2002) Nausea and vomiting of pregnancy: an obstetric syndrome. Am J Obstet Gynecol 186: S184-S189. to high levels of HCG for the first time [20]. 9. Allen K, Feeney E (1997) Alcohol and other drug use, abuse, and dependence. In: K Allen, J Phillips (Eds). Women’s health across the Limitation of the Study lifespan: a comprehensive perspective Philadelphia, PA: Lippincott 311-332. As most of the respondents were in advanced gestation during the 10. Bühling KJ (2008) Nausea and hyperemesis Gravidarum. Gynakol interview, with no custom of keeping health diary or menstrual Geburtsmed Gynakol Endokrinol 4: 36–48. calendar, the possibility of information (recall) bias cannot be 11. Flaxman SM, Sherman PW (2000) Morning sickness: a mechanism for excluded. protecting mother and embryo. Q Rev Biol 75: 113-148. From this cross-sectional study, it is impossible to determine causal 12. Gazmararian JA, Petersen R, Jamieson DJ, Schild L, Adams MM, et al. relationships. (2002) Hospitalizations during pregnancy among managed care enrollees. Obstet Gynecol 100: 94-100. 13. Hellerstedt WL, Pirie PL, Lando HA, Curry SJ, McBride CM, et al. (1998) Conclusions and Recommendations Differences in preconceptional and prenatal behaviours in women with intended and unintended pregnancies. Am J Public Health 88: 663-666. In this study, severe NVP accounts for 8.2%, which is comparable to 14. Hod M, Orvieto R, Kaplan B, Friedman S, Ovadia J (1994) Hyperemesis the currently available body of literature. Sever nausea and vomiting is gravidarum: a review. J Reprod Med 39: 605-612. higher among those not living together, in the first trimester, not 15. Jordan V, Grebe SKG, Cooke RR, Ford HC, Larsen PD, et al. (1999) employed and nullipara women. Since this study cannot show Acidic isoforms of chorionic gonadotrophin in European and Samoan significant association, further studies with large sample size and that women are associated with hyperemesis gravidarum and may be assess associated factors are needed. thyrotrophic. Clin Endocrinol 50: 619-627. 16. Hod M, Orvieto R, Kaplan B, Friedman S, Ovadia J (1994) Hyperemesis Authors’ Contribution Gravidarum: A Review. J Reprod Med 39: 605-612. 17. Lacasse A, Rey E, Ferreira E, Morin C, Berard A (2008) Nausea and GK wrote the proposal, participated in data collection, analyzed the vomiting of pregnancy: what about quality of life? BJOG 115: 1484-1493. data and drafted the paper. ShG, TG and TW approved the proposal 18. Goodwin TM (2002) Nausea and vomiting of pregnancy: An obstetric with great revisions and revised subsequent drafts of the paper. All syndrome. Am J Clin Exp Obstet Gynecol 186: S184-S189. authors read and approved the final manuscript. 19. Jennifer K (2010) Nausea and Vomiting in Pregnancy: Prevalence and Relationship with Psychosocial Determinants of Health; (Unpublished Competing Interest doctoral thesis), University of Saskatchewan, Saskatoon, Saskatchewan. 20. Jarnfelt-Samsioe A, Samsioe G, Velinder GM (1983) Nausea and vomiting The authors declare that they have no competing interests. in pregnancy - a contribution to its epidemiology. Gynecol Obstet Invest 16: 221-229. 21. Davis M (2004) Nausea and Vomiting of Pregnancy; An Grudzinskas JG Acknowledgement Hyperemesisgravidarum, an evidence-based review. J Perinat Neonatal Authors would like to thank Arba Minch University, College of Nurs 18: 312-328. medical and health sciences, school of post graduate studies for 22. Mazzotta P, Magee LA (2000) A risk-benefit assessment of initiating them to conduct this study. Deep appreciations have gone to pharmacological and nonpharmacological treatments for nausea and vomiting of pregnancy. Drugs 59: 781-800. Arba Minch General hospital administration. Special thanks to all respondents, data collectors, supervisors and all peoples who involved 23. Miller F (2002) Nausea and vomiting in pregnancy: the problem of perception-is it really a disease? Am J Obstet Gynecol 186: S182-193. in the study directly or indirectly. 24. Fejzo MS, Poursharif B, Korst LM, Munch S, MacGibbon KW, et al. (2009) Symptoms and Pregnancy Outcomes Associated with Extreme

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Clinics Mother Child Health, an open access journal Volume 15 • Issue 1 • 1000285 ISSN:2090-7214